THURSDAY, May 21, 2015 (HealthDay News) -- Cigarette smoking continues to decline in about half of American states, according to the latest U.S. government estimates.

But despite that good news, rates have gone up in some states. And in other states, a more worrisome trend has emerged -- people using a combination of tobacco products, such as cigarettes plus smokeless tobacco, officials said.

"From 2011 to 2013 although we've seen some progress for cigarette smoking overall, there hasn't been a significant change in cigarette smoking or smokeless tobacco use across many states," said Brian King, acting deputy director for research translation in the Centers for Disease Control and Prevention's Office on Smoking and Health.

"What is most concerning is the preponderance of dual use -- people using multiple tobacco products," King said. "That's concerning because we know that dual users have a higher level of nicotine dependence and they are also less likely to quit."

Smoking declined across the nation from 21 percent of adults in 2011 to 19 percent in 2013, according to the report.

Among states, however, vast differences in smoking rates exist, researchers said. In fact, in 2013, rates varied from a low of 10 percent in Utah to a high of 27 percent in West Virginia.

For smokeless tobacco, rates also varied widely in 2013. Only 1.5 percent of people used smokeless tobacco in the District of Columbia and Massachusetts, but more than 9 percent of people in West Virginia did, the researchers found.

From 2011-2013, cigarette smoking declined in 26 states. But smokeless tobacco use declined in only two states, Ohio and Tennessee. On the other hand, smokeless tobacco use increased in four states -- Louisiana, Montana, South Carolina and West Virginia.

Moreover, the combined use of cigarettes and smokeless tobacco increased in five states -- Delaware, Idaho, Nevada, New Mexico and West Virginia.
Smokeless tobacco isn't risk-free, King pointed out. It's a known cause of cancers of the mouth and throat, he said.

King said there are proven ways to get people to quit using tobacco. These include increasing the price of tobacco, enacting smoke-free laws, and media campaigns that expose the dangers of tobacco and the benefits of quitting, he explained.

"The states where we see the lowest tobacco use and the most marked declines are the ones that implemented these interventions," King said.

However, he acknowledged that increasing the price of cigarettes may be driving the increase in the use of cheaper alternatives such as smokeless tobacco.

"We know that increasing the price of tobacco is the most effective method to reduce consumption," King said. "Since smokeless tobacco is taxed lower in most states along with other products like e-cigarettes, this could be contributing to the lack of decline in use," he said.

King said that only Alaska and North Dakota spend the dollars they got from the 1998 tobacco settlement between the states and tobacco companies, as well as revenue from tobacco taxes, on smoking-cessation programs at CDC-recommended levels.

"Despite states collecting about $25 billion in 2015, they're spending less than $500 million -- about 2 percent -- on tobacco control," he said.
The new report was published May 22 in the Morbidity and Mortality Weekly Report.

Dr. Norman Edelman, senior consultant for scientific affairs at the American Lung Association, said the association agrees that states spend too little on helping people quit tobacco.

"Smokeless tobacco is cheap," he said. "States have not raised taxes on it the way they have on cigarettes, and high prices are one of the best tools we have in combating the use of tobacco," Edelman said.

He added that broader regulation of all tobacco products is needed, including e-cigarettes and little cigars that look like cigarettes but are not regulated like cigarettes.

"We need the FDA (Food and Drug Administration) to bite the bullet and issue final regulations on e-cigarettes, and we need a more comprehensive approach to the regulation of all tobacco products," Edelman said.